powerpoint presentation 2020... · 2010 scoring range by category item 0 10 20 30 40 50 60 70 80 90...

iPEX 2020

Karen Kiel RosserRon Smith

Building a Strong Baldrige Application

Demonstrate how a commitment to the Baldrige Framework can strengthen your application through

1. Fostering organizational learning

2. Learning from others

3. Sustaining results

Objectives

Leadership Commitment to Consistency

Investing in Our People

Multiple Methods of ImprovementService and Process Improvements 6.1b(4)

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2010

Leadership

Strategy

Customers

Measurement, Analysis and Knowledge Management

Workforce

Operations

Healthcare and Process Results

Customer-Focused Results

Workforce-Focused Results

Leadership and Governance Results

Financial and Market Results

Form Follows Function – 2011Continuous improvement and Innovation 4.1c(2)

• Standard Work Steering Committee • To further support our lean culture

• Focus on where improvement is needed

• Systematically identify and select projects

• Organize work

• Create standard work documents

Managing

Bedside Equipment

• Expected Benefits:• Less shortages of key equipment

• Less traveling for pumps (inventory locations closer to use)

• Less searching (fewer & standard locations)

• Self-serve (eliminates TDSS requests, Transport wait time, Central Stores involvement)

Improvements:• Reduce the number of locations where critical equipment is stored

• Clearly defined cleaning responsibilities & priority• Extra units stored next to highest volume users

Sitting: Amanda Lass, Laura Deal, Melissa K. PetersonStanding: Ron Smith, Karen Kiel Rosser, Matt Aitchison, Cathy Wright, Jon Barton, Brendy Pierce, Andrew Dinsdale, Tim Bartholomew

Baxter’s Big Adventure!This swim lane chart shows the steps

required to locate a clean Baxter IV pump today. The majority of the steps add no

value to the patient.

3. Clean Clamp and Cord with CAVI Wipes* CAVI wipe dwell (wet) time = 3 minutes

Bedside Equipment CleaningB Braun Stackable IV Pumps

B Braun IV Pumps

Personal Protective Equipment Supplies

Gloves CAVI Wipes

* Bleach towelettes required for special contact precaution isolation.

4. Inspect pump – send to SPD, if grossly soiled Complete and tag with FAILED EQUIPMENT FORM

6. Wrap cord counterclockwise and secure

1. Disassemble clamp and pumps 2. Clean each pump with CAVI Wipes*

Remove Clamp Separate pumps Outside of pump Inside of door

Depress button and squeeze handle

Pull to slide and remove clamp

Depress button and slide to separate pumps

5. Reassemble pumps and clamp

Name Title Date

Cathy Wright Director of Guest Services

Melissa Peterson Supervisor of Guest Services

LeAnn Hillier Infection Control

Matt Aitchison 2 South Clinical Supervisor

Amanda Lass ADT Nurse, 3 South

Approvals:

•Grooves and face•All sides, top and bottom

To open door press and hold power.

Clean:•Inside of face•ChannelTo close, lift door and

hold power for 3 secs.

Project Management Software

• Document and manage improvement projects

• Central location for resources and team member communication.

Preventable Harm Index

Preventable Harm Index (PHI)

112119

114120

107

130

13 1421

13 159

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2014 2015 2016 2017 2018 2019

Overall Preventable Harm & Serious Safety Events (SSE)

PHI Serious Safety Events (CMS Reportable)

FY2019 = 40% reduction in SSE

2011-2012 Scoring Range by Category Item

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2010 2011 2012

Leadership

Strategy

Customers


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Operations






Strategic Planning Steps

• Data / Environmental Scan

• Assumptions

• Plan Objectives

• Metrics

Standard Work for Rapid Improvement EventsService and Process Improvements 6.1b(4)

Pre-work meeting(30 days prior to event)

3 Day Rapid Improvement Event

Finalize Logistics• Schedule Room• Confirm/Invite Participants• Gather Background Information• Additional Event Preparation

First Friday Report Out*

30 Day Follow-up Meeting



*First Friday of the Month Following Event Completion

Identify Key Work ProcessesKey Work Processes 6.1a(2) and Support Processes 6.1b(3)

Top Ten Value Streams

1. Operating Room

2. Emergency Room

3. Lab

4. Medication Management

5. Continuum of Care

6. Home Health

7. Registration

8. Pre-Authorization/Pre-Admitting

9. Bed Placement Schedule

10.Discharge


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2010 2011 2012 2013

Leadership

Strategy

Customers


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Operations






100 Day WorkoutProcess Efficiency and Effectiveness 6.2a

100 Day Workout Timeline - 2014

Jan. 2014 Feb. 2014 March 2014 April 2014 May 2014

100 day work out projects due

Senior leaders review and approve all projects

Meet with VP to establish final 100 day plan

First 30 day follow up with VPs; select projects reported to leaders

2nd follow up with VPs; Check-in/Questions from Leaders

Final 100 Day Workout report out celebration

Project results validated w/ Finance

100 Day Workout Common Themes

• Cost Savings• Contract Renewals/Re-Negotiations

• Inventory Management/Reduction

• Savings on Medications/Supplies

• Revenue Generation• Sell used equipment

• Review charges for accuracy

• Increase volumes

The Turning Point

Process Results


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2010 2011 2012 2013 2014

Leadership

Strategy

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Multi-Disciplinary Strategic Planning Team2016-2019 SPP

• SP Task Force

• External strategist as facilitator

• Comprehensive focus group Sessions• External

• Internal

2016-2019 Strategic Plan Strategic Planning Process 2.1a(1); Vision, Values 1.1a(1) and Strategic Objectives 2.1b

Asking Every Day

• Are there any problems interfering with your work?

• With patient care?

• Have you had any ideas for improvement lately?

• Do you have what you need to do your job?

Doing What’s Right: Patient-Centered Scheduling

• Customer Expectations

• Improvement

• ADLI

• Results

2015-2016 National Baldrige (MBNQA)Scoring Range by Category Item

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2014IRPE 2015MBNQA 2016MBNQA

Leadership

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Learning from Other Baldrige Recipients

Employee Focus Groups

Creating a Focus on Action - Big Dot Goals Key Performance Measures 2.2a(5) and 4.1a(1)

Work System Maps

Identify Key Work ProcessesKey Work Processes 6.1a(2) and Support Processes 6.1b(3)

Work Systems MappingBest Practices 4.2b(2)

How do we use the map?• Recruiting/Interviews• Orientation for new staff• Identify Best Practices (What we

do well)• Identify Issues (Areas to improve)• See your individual contributions • Show the organization and other

departments “What you do.”• Understand how you interact and

connect to other departments

Organization Goals

Key Work System

Department Processes

Individual Processes

Work System Map Development

1. Director, Supervisor, Manager set direction by identifying Department Processes

2. Staff, using sticky notes (one process per sticky note), identify individual work processes (tasks performed

on a daily/weekly/monthly/quarterly/annual basis). There is no wrong answer.

3. Director, Supervisor, Manager consolidate staff feedback

4. Staff provide final approval/changes

5. Send to print

Results Index

2017 National Baldrige (MBNQA)Scoring Range by Category Item

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2015MBNQA 2016MBNQA (BSVE) 2017MBNQA

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2015MBNQA 2016MBNQA (BSVE) 2017MBNQA 2018MBNQA

Leadership

Strategy

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Strategic Plan Framework

Employee Goal CardsCreating a Focus on Action 1.1c(2)

Tiered Daily Safety HuddlesPatient Expectations and Preferences 6.1b(2)

Patient & Family Advisory CouncilListening to Patients and Other Customers 3.1a

Received the 2019 CMS

Challenge Coin from the

Quality Improvement &

Innovation Group

Consistency, Commitment to Excellence & Sustainability


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2015MBNQA 2016MBNQA (BSVE) 2017MBNQA 2018MBNQA 2019MBNQA

Leadership

Strategy

Customers


Workforce

Operations






And then we finally got the

right team of examiners….

Lessons Learned throughout the Journey

• Make Baldrige about how you do business. . .everyday.

• Senior leader engagement is vital.

• Be willing to accept feedback and focus on incremental improvement.

• Focus on beneficial results rather than on winning.

• Never lose sight that your organization is improving, even if you haven’t achieved your ultimate goal.

• Don’t cram for the test (site visit), let your employees live it.

• Build your internal expertise to support the work you do every day.

Keys to Success at Mary Greeley Medical Center

• Senior Leader engagement and discipline

• Baldrige criteria provides a Framework for Excellence• Annual application submission provides rigorous self-

assessment.

• Feedback report supports annual action planning.

• Our work and the Mission, Vision and Values of the organization align with the Baldrige Core Values.

• The Baldrige process becomes part of the work we do everyday.

Ron SmithPerformance Improvement [email protected]

Karen Kiel-RosserVice President, Quality Improvement Officer [email protected]

mailto:[email protected]

mailto:[email protected]

powerpoint presentation 2020... · 2010 scoring range by category item 0 10 20 30 40 50 60 70 80 90...

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